Louise King

Good evening, welcome to today’s webinar on varicose veins by Benenden Hospital. I’m your host and my name is Louise King. Today’s presenters are Mr Eddie Chaloner and Mr Aaron Sweeney. They’re Consultant Vascular Surgeons at Benenden Hospital.

The presentation will last approximately thirty minutes followed by a Q&A session. The Q&A session will be a point where you can ask questions at the bottom of the screen by the Q&A icon. If you could try and use this icon versus the chat icon that’d be perfect. We will answer as many questions as possible and any that we can’t answer in the session we will do so via email afterwards. You can ask the questions using your name or you can tick a box to say you want to be anonymous.

Please note that this session is being recorded as well and finally, after this session, we will have our Private Patient line open from 7pm. If you wanted to book any consultations, we have Karen and Emma on the line to speak to you. So, I’ll now hand over to Mr Eddie Chaloner. Thank you, Eddie.

Mr Chaloner

Thanks very much Louise and thanks everybody for joining the webinar tonight. I'm obviously on the left-hand side of the screen and Aaron, my colleague, is on the right.

We've been doing the varicose veins service at Benenden now for over 10 years, so we're pretty well established down at Benenden and indeed we've been doing varicose vein surgery for considerably longer than that. We were the first surgeons in London and the South East to use the Endovenous Laser technique for varicose veins back in 2002-2003, and this has really changed the way treatment for this very common condition is delivered and improved it beyond all recognition.

When Aaron and I were young surgeons, training, we learned how to do an operation called the high tied strip and that was the only operation for varicose veins there for about 100 years, and it involved always putting patients to sleep and making big holes in the skin in order to do the operation. It took around about six weeks for people to get better from that procedure. But with the advent of minimally invasive techniques to treat varicose veins, we can do most of our work with a local anaesthetic. We don't have to put people to sleep and most people get better within a couple of weeks. We've got a lot of experience with this; we've probably done more varicose veins than any other surgical practice in the entire country over the last twenty years.

Virtually all varicose veins these days can be fixed with minimally invasive treatment. Now people often wonder what ‘minimally invasive’ means. Well, it's not a magic wand! We do have to put things inside the body in order to achieve the effect but the difference between minimally invasive surgery and one that’s called standard or open surgery (I prefer the term old-fashioned, although some people might argue with that!) is that we make very much smaller incisions. In fact, the incision we need to make to insert the laser is around about two or three millimetres, so you can barely see it even after we've finished. The essence of minimally invasive treatment and the sort of practical philosophy behind it is to keep the same results as you would with standard open surgery, but to do it without causing what might be termed collateral damage to surrounding structures or making very big incisions in the skin.

There's no doubt that the minimally invasive surgery - not just in varicose veins, but for taking out gall bladders or appendixes or colons - has really become very well established as the treatment of choice in virtually all specialties. As I mentioned previously around 90 percent of cases can be performed under local anaesthetic so it's really a bit like going to the dentist in some respects. Now when I say local anaesthetic I don't mean to imply, as you may see on somewhat misleading adverts on the internet, that this technique is painless - because it isn't. In order to deliver the local anaesthetic, we do have to do some injections in the leg in the same way that the dentist has to do some injections in your mouth, and that hurts a bit. But for most people they find it quite tolerable.

There are some patients who are very nervous about local anaesthetic injections, as there are when people go to the dentist, and for those patients we can give a sedative or a tablet. Generally, we usually use a tablet called Temazepam which is a very well-established tranquiliser-type medication and normally we find that if people are very nervous about injections that solves the problem. It makes them more relaxed, and they find that the procedure really is quite tolerable. Occasionally, we do give patients a general anaesthetic, well that's very rare, it's probably about two or three percent of cases and it's usually either because patients choose that - because there really are some patients who are just very, very needle phobic and they’re frightened of needles in this basic procedure and if patients want to have general anaesthetic there’s no problem with doing that. Very occasionally there are cases where we actually technically can’t do it with the minimally invasive procedures under local anaesthetic and we need to have a general anaesthetic but that’s really very uncommon.

At Benenden we do somewhere around seven to eight hundred cases per year and that’s about half of our total practice. That's the biggest volume veins centre, certainly in the South East, probably in the whole of England.

Now people wonder ‘what are varicose veins?’ because they're extremely common and broadly speaking this is all about the way the blood flows in your leg. There are two sorts of blood vessels in the leg: there are the arteries which take blood down to the leg muscles, and the veins which bring the blood back up the leg. Now obviously the blood in the arteries is pushed down the leg by the heart, which is essentially a pump, and the blood comes back up the leg by use of the calf muscle. When you contract the calf muscle it squeezes the veins and pushes the blood back up. But because the calf muscle doesn't contract all the time, you have to have valves in the veins to stop all the blood ending up into your ankles. Varicose veins occur where those valves are blocked and the blood pools in the lower part. The patient notices this as swollen purple or blue veins that stick out and are lumpy, bulging or twisted in appearance, and the consequence of the blood pooling in the leg is that the legs tend to ache, they feel heavy and uncomfortable, and patients get swollen feet and ankles and the sensation is often referred to as a cramping or burning or throbbing sensation - usually after you’ve been standing up all day.

And if this goes on for long enough, because the pressure in the veins is too high it can start to damage the skin over the lower part of the leg, usually around the ankle, because that's the area of highest pressure. This manifests itself as a darkening of the skin, or dilatation of veins in the lower part around your ankle. Then sort of itching and dryness of the skin and a discoloration. It starts to look brown and slightly dry.

Now I'm going to hand over to Aaron at this point and he's going to talk about how we classify veins in order of severity and what that means as far as treatment’s concerned.

Mr Sweeney

Thanks a lot. Good evening.

There are six different grades of varicose vein problems and normally that doesn't really matter to people reading about it - most times it's just small veins or big veins. We start off with the smallest type, which are those that you can see on the surface and these generally don't cause any medical problems but can be a little unsightly and many people find these very irritating. We can treat those, we normally treat those with sclerotherapy, which is where I or Eddie will inject a small amount of a chemical which irritates the vein, causes it to block off and then it eventually dissolves and disappears.

It sounds quite easy, it is a little technical, it sometimes takes a few treatments to get a very good cosmetic result and it can produce some bruising and skin staining which looks a little brown in colour which eventually disappears. But it is a treatment that's very effective, but it does take quite a few weeks to settle down and look good. There are many different treatments for smaller thread veins and the reason there are many treatments is because no one treatment works perfectly. But we use injection (sclerotherapy) because we think it's the best. We have used skin lasers and a machine called a pulse light laser and they work all reasonably well but just we found that sclerotherapy was the best. These types of veins are not generally troublesome although occasionally they can bleed. Next slide please.

Grade two are just a little bit bigger, they're normally veins you can start to feel and then they again usually don't cause any trouble and are mostly cosmetic but they can be a little uncomfortable and can produce some itching. Again, we prefer to treat those with sclerotherapy but sometimes we will do a tiny little incision to remove them. They again are troublesome and sometimes take a few goes to get a very good cosmetic result but in general we get reasonable results with those. Next slide please.

This really is what we would call medical veins. These are veins that are enlarged and starting to cause a little bit of trouble and that trouble can be, as Eddie mentioned, pain, aching, light cramps, skin that becomes itchy, or that awful heavy feeling that you get at the end of the day. These are really the type of veins that insurance companies allow you to have treated and they generally regard anything smaller as being purely cosmetic. With these veins there is an option of injection sclerotherapy, but we prefer not to do that.

We don’t think it’s a very effective way of treating them and it does produce a lot of discoloration in the skin when you treat large veins with injections. Interestingly, sometimes people can see a small vein or a few veins on the surface and they wonder – ‘why would that vein be producing so much discomfort in my leg?’ – and the answer is that all you're seeing is just the tip of the iceberg. Nearly always, just underneath the surface there is another vein and that can run the entire length of your leg. So, it can in some circumstances be sixty centimetres long and it's all filled with blood and it's a bit like a yard of ale just sitting under the skin and all you see is the small vein at the surface. But the reason you're getting so much pain is that vein is in fact quite large, you just can't see it. So normally when veins start to be become uncomfortable, they're at least grade three and they're usually the veins we start to treat with lasers. Next slide.

Now grade four is really when people have varicose veins, but they are not really sure if they're causing any trouble, so quite often people get itchy skin or eczema or start to get some discoloration of the skin. Often, they will think it's perhaps just a little bit of eczema and they try various steroid creams and often this goes on for quite some time - it can be many years. Grade four is when the skin starts to become discoloured or damaged and that's often when it becomes scaly or brown in colour and it's really a sign that the vein has gone from being just an annoyance to a proper medical problem.

If left untreated, this will almost invariably continue to irritate your skin and in the worst-case scenario you can end up with bleeding or even an ulcer. Our next pictures are a little bit gruesome because they do show skin that has been damaged and Eddie and I always feel that this is a complete failure because this could have been caught many years before and treated. We feel it is a little depressing when patients come to us and they have an ulcer and they're in dressings and really their life is turned upside down and both of us feel that that could have been stopped many years before, if only they'd realised that it was a varicose vein that was causing all the trouble.

So, I think we might just show the next slide briefly just to not turn you off your dinners, but essentially this normally doesn't happen after a few months, that's normally years and years and unfortunately it nearly always occurs in people who didn't realize that the skin irritation and the skin discoloration was caused by a varicose vein. Indeed, if you can stomach looking at those pictures, you'll see that you can't really see any varicose veins nearby.

It is not unusual to have a very large varicose vein that can be twenty or thirty centimetres long and the size of your thumb just sitting under the surface and not really that visible but allowing blood to pool around your ankle, damage the skin and then all it requires is a small little knock or damage by a shopping trolley and all of a sudden you end up with an ulcer and the average length of time that those ulcers stay is over a year and, to be honest, I don't think you ever recover fully from this. We can treat that, we do usually laser the vein that's causing the problem and we can get rid of the ulcer, but the skin remains scarred, discoloured and it never goes back to being normal again. Back to you now, Eddie, I think.

Mr Chaloner

There we go, good, yeah thanks Aaron. So that's a pretty good summary of the range of problems we get with veins -  from the purely cosmetic all the way to the very seriously medical problematic part. The essence of treatment is really to seal the leaky vein.

As Aaron said the visible veins that you can see in the calf are usually the tip of the iceberg and it's usually what we call a trunk vein or the saphenous vein, which is inside the leg and can't be seen with the naked eye, but we can see it with ultrasound which we use all the time in clinic on every patient that we see. We can see where the veins you can see on the surface, where they are actually being filled from and often times it's the long saphenous vein which runs down the inside of your thigh. You can see here on the graphic it starts around the knee and it’s going all the way right up to the top, and then the top part, where it's very narrow, has been sealed now as the laser is drawn back down the thigh.

Then eventually, the lower part where it's blue will also be sealed and basically, we burn the inside of the vein with the laser. That sounds like an utterly hideous thing to do to somebody, but it works extremely well. It works a lot better than the alternative which is when we cut people in the top of the leg in the groin and strip the vein out with a big plastic rod. Aaron and I did hundreds and hundreds of those operations when we were younger surgeons and there's no question that everyone's forgotten about what that used to be like. But it was miserable – we used to have patients coming back to clinic with wound infections, big bruising, lymphatic leaks in the groin and nerve injury. The complication rate was around about ten percent but, having got skilled at using the laser, it's very rare to have a serious complication these days.

Now a laser is not the only option, there are others, and you will read about them if you do some research around this point. The commonest technique, other than the laser, is a thing called radiofrequency and that, broadly speaking in layman's terms, is pretty much the same thing. It's the use of heat to damage the vein to get it to seal and the difference is that lasering is heat generated by amplified light and radiofrequency is heat generated by electricity. In practical terms, there's virtually no difference.

And then there are the chemical techniques - sclerotherapy Aaron has already mentioned - and that is a very good technique done for the right type of veins. But for bigger veins Aaron and I don't think that works very well for the reasons he's given. It makes you lovely and bruised for a long time and it also has a very high recurrence rate. You see the newer techniques - Clarivein that's a hybrid technique of a chemical and a mechanical technique combined.

We were the first surgeons in the UK to use that operation and it does have some very good points, but the problem we found and the reason we stopped doing it as a choice is that it has a high recurrence rate. Around about 20 percent of patients will get their veins back again within two years of Clarivein, whereas with the laser the recurrence rate is more like five percent - so, one in 20 at five years. And then finally you may come across the technique called glue which is a simple super glue - basically tissue glue. That has been used but again that can be quite successful, but there are really difficult, really very challenging side effects where patients have had what we call skin necrosis, where the skin over the vein is completely broken down and caused an ulcer from the operation. We've never had a problem with that because we've never used it but that has been reported and, for that reason, we steer away from glue, mainly because we think the laser is a very good operation. It's not perfect but it's pretty good and on balance we think it's the best technique available.

So, before we decide what the patient requires, we need to have a consultation at which essentially, we take a history and we examine your leg, including looking at it with an ultrasound to find out where the problem’s arising from. Because as Aaron mentioned, the bit you can see is the tip of the iceberg. It's the bit inside your leg which is the most important part. If you don't get that bit right, then whatever you do to the bits that you can see won't work.

Having done that and figured out where the technical problem is, we then decide what the best surgical option is and whether or not we can do it under local anaesthetic, under local anaesthetic with a sedative, or whether in rare circumstances a patient needs a general anaesthetic for technical reasons or reasons of choice. But 95 percent of our patients have a local anaesthetic operation and effectively it's walk-in, walk-out. Most patients come in and the operation itself takes around 25 to 30 minutes, and then they go through to recovery for a cup of tea and you know, very shortly afterwards, they're able to go home. So, the whole thing, usually for most patients coming in the door to going out the door takes about two hours.

This is an appearance, you know, to show you the appearance of the pre-op on the left-hand side, then the middle one is two weeks after surgery and then the one on the right is six weeks after surgery. Now bear in mind that nobody, including me, ever shows you a bad slide of an appearance okay. We always like to show our successes and you can see this is pretty successful. It doesn't always look quite as perfect as that, but generally speaking, we hope to make all the aching and throbbing go away and from the cosmetic side of things we like to think we can almost always get people to be able to wear knee-length garments in public without being self-conscious about it. We can't make you look like a marble statue, I’m afraid or put you back on the catwalk but we can usually get you to a point where you can, you know, go to the swimming pool and do all your normal activities without thinking everyone's staring at your legs.

I think that's about it from our chat point of view. We're very happy to take any questions. I can see some people have already put questions up and Louise will moderate that and then Aaron and I will just take it in turns to answer the questions for about 15 or 20 minutes. So back to Louise now.

Louise King

Thank you, Eddie.

Okay let's go through the questions. The first question is how much do hormones, and therefore pregnancy affect the formation of varicose veins? I’ve recently given birth and I am now suffering with painful, veiny legs.

Mr Sweeney

Yeah, I can answer that if you'd like. Interestingly, ladies have an extra problem in that one of your hormones - which is progesterone - essentially you get a spike just before a period and just before a baby comes out. Progesterone has many effects but one of its effects is that it relaxes things to allow a baby to appear. It also relaxes your veins and that's why in the last trimester, if you have varicose veins, they become much larger and give you much more throbbing. It can also lead to things such as piles. But part of the leg swelling that occurs in girls just before a period is due to progesterone and it’s made worse by if you have a varicose vein. Nearly always if you have varicose veins and you get pregnant, they become a little worse. They often become quite bad just before delivery and afterwards they improve a lot. They often go back to the way they were before but they can remain quite large. But your hormones do play quite a major part and blokes like myself get away with this because we don't have progesterone.

Louise King

Thank you. Okay next question. If after the ultrasound you find that veins are larger than they appear from the outside, would you suggest a general anaesthetic?

Eddie, did you want to answer?

Mr Chaloner

Not usually. The laser technique will fix just about any diameter of saphenous vein. The normal diameter of the saphenous vein is around about three to four millimetres and in really bad cases of varicosities it can be dilated up to 10 millimetres or even more sometimes. But almost always that's treatable with the laser. There are very few circumstances where it isn't and almost always it can be done under local anaesthetic. Now the real difference, or the thing we adjust in our technique, if you have a really big vein say nine to ten millimetres, we pull the laser fibre back slower. Normally if it's a standard vein, which is five or six millimetres, we will withdraw the fibre around about one centimetre every five seconds which delivers around about 70 joules per centimetre of energy. But in a really big vein where we have to burn it a little bit harder, we just pull it back slower and we might go up to 80, 90 or even 100 joules per centimetre in order to get the vein to close and that's one of the I guess the technical tricks which allows us to do effective operations with the laser on even really quite large veins.

Louise King

Thank you. Okay next question. What are the benefits of varicose vein treatment at a hospital instead of a clinic? Aaron, do you want to go with this one?

Mr Sweeney

I think you can indeed have your veins treated in a clinic. Many people do that. It's not an unreasonable thing to do. Eddie and I have chosen not to do that and our reason is really to do with complications.

It doesn't matter really how good you are, you always have complications and if you only do a small number of procedures then you won't encounter those complications often. We do many thousands of procedures a year. So even if we get one in a thousand major complications that's actually quite dramatic for us and I always worry that if you're in a clinic on your own, not surrounded by other staff that can help you that you're at a bit of a disadvantage. It really only takes one disaster for you to realise you're in the wrong place.

So, we prefer to operate at a proper hospital and indeed we operate in Benenden. But we also operate in central London and indeed we have shied away from doing treatments in a clinic. However, plenty of people would have a different opinion on that and think that their treatment in the clinic is entirely reasonable and safe. So, it's a personal preference. We prefer to do it in a hospital which is totally sterile and with properly trained staff. We feel much more comfortable, and it also means you can deal with complications very quickly, very effectively and it leads to happier patients if you don't allow things to progress. So that's the reason we use hospitals but as I say other people have different opinions so I wouldn't say it's bad to have treatment in a clinic, I just don't do that.

Louise King

Thank you. Okay can varicose veins come back after treatment and if so, are they as severe as the ones that have already been treated?

Mr Chaloner

Well, yes, they can. When we used to do the old operation, the high tied strip, the recurrence rate was about thirty percent at somewhere between every two to five years and quite often the veins came back in a very major way. They did recurrent substantial surgery which got more and more technically difficult, the more recurrence there was. These days, even with minimally invasive techniques, a recurrence can happen but it's very much less common. It's around about five percent if you look at outcomes. And of that five percent, most of those recurrences are not what we as surgeons would call true recurrences. In other words, it's not that the vein that was treated has come back again, it's that another vein in the system has opened up. So, from our point of views as technicians, we would call that a second primary event but from the patient's perspective of course it's a recurrence because you've had your veins operated on and they come back again. And to the point of how severe can the recurrence be? Well, most of the time it's not terribly severe, it's usually fairly straightforward to fix, either with repeat lasering if it's a new vein that's opened up or foam sclerotherapy. The recurrences are both less frequent and less severe with minimally invasive treatment than in with the way that Aaron and I did it 20 years ago.

Louise King

Yeah, great thank you okay. We have a question that, well one lady has asked three questions, so we will try and go through those, Aaron. First is, how likely is it to get a blood clot from varicose veins? What grade onwards give the more likeliness of that? That's the first phase of the question. Would you like to answer that now or shall I go on?

Mr Sweeney

I can answer that. Your risk of a DVT is much smaller than you might think. We do audit all our results at Benenden and indeed elsewhere and your risk of a DVT is about one in a thousand with EVLT. It's much higher than that with the older procedure but one in a thousand is the risk. I would say that DVTs, which are a clot in the big vein in the leg, are very rare but they occur in people who are not mobile after an operation. So, you will find that me and Eddie constantly tell you that you have to be mobile and up and walking. If you're not up and walking you get in contact with us, we get you back and wonder why you're not walking; it's nearly always to do with discomfort. The commonest reason people aren't walking perfectly after the operation is because I’ve put the bandage on a little bit too tight and it's uncomfortable. So, I just replace the bandage and everything gets back to normal. So, your DVT rate is about one in 1000 which is pretty low, and to put that into perspective having a baby has a risk of one in a 100 of a DVT, and if you broke your leg while skiing your risk is about one in ten. So, they're pretty high risks and then to give you another bit of stats, your risk of a DVT when flying in an airplane is about one in a million just in case you think it's any higher than that.

Louise King

Thank you, another part of their question is, can sliding down garments which wrinkle the skin, cause or worsen varicose veins?

Mr Sweeney

No is the answer to that, we don't really know why varicose veins occur, we know a valve breaks, but we don't know why. Crossing your legs, doing gymnastics, running too much or too little, being heavy or being skinny, none of those things make any difference. Most of those are old wives’ tales and I think we as surgeons usually tell people we don't know why they occur whereas I think a lot of people like to give you a definitive answer, that the reason you have varicose veins is because you are 16 stone.

That's just not true. Sometimes if you're 16 stone and you have a varicose vein your legs are achy, but it might not be the varicose veins causing all the ache. But either way being heavy doesn't necessarily cause you to have varicose veins.

Louise King

Thank you, and they say also how many laser treatments do you need for each grade of veins to solve the problem usually?

Mr Sweeney

Well, yeah, normally when we say ‘laser a vein’ what we mean is ‘laser the veins’. So sometimes you can have two veins and really very occasionally three veins, that are not working in your leg in which case we just thread the laser up each of those veins individually and zap them. So, one treatment effectively is all the veins done in one go, so it might take a little longer to do an extra vein but most times it doesn't - but we would treat the whole of your leg in one go.

Louise King

Great thank you. Paula says do thread veins always develop into a much bigger and painful veins early?

Mr Chaloner

Yeah not usually. If you've just got isolated thread veins and there's no underlying valvular leak, then that doesn't predispose you towards developing varicose veins at a later stage. Having said that a lot of patients come with what they think are thread veins - and indeed are thread veins - but when we examine the leg and use the ultrasound scanner, we see they've also got varicose veins at the same time. Now in that circumstance the correct thing to do is to fix the varicose veins first, because if you just do the thread veins with injection sclerotherapy it won't work. Or then it'll work for a very short period of time, then they'll come back again.

So the sort of order of batting if you like is to do the most severe bit first and then work down from there. But there aren’t many people who just have thread veins honestly on their own, which are no problem really other than just the cosmetic appearance, and we inject them in clinic and get them to go away. And if you have isolated thread veins it doesn't mean that you're more likely to get varicose veins in the future. But the two things can occur at the same time.

Louise King

Okay, thank you. An anonymous person says they have at least grade three to four veins but only have occasional night cramps, no itching. Should they get them removed Aaron?

Mr Sweeney

Yeah, not necessarily there. So, the absolute reason for getting your veins treated is if your skin is damaged. Ache and pain probably there's no real urgency so you shouldn't be frightened into having a vein operation just because of the grade, whether it's two or three. If it gets to four, and that's this where the skin is becoming damaged or changing colour, we know that that will progress. And if you leave it alone it just gets worse and worse. So, if you came to us, we would tell you these are your options, we always give you the option of leaving them alone and telling you what happens. But nothing really ever happens within a few months so most people we would tell, we would advise you not to leave it for a few years. But if you’re not itching, occasional night cramps is not something that we would say you have to have an operation.

We might say to you maybe wear a compression stocking and see how that goes. I would say most people hate compression stockings so it's really only a temporary measure, but some people they are absolutely against an operation which is entirely reasonable, and a compression stocking can keep things at bay. So just a bit of itch and a bit of night cramp is not enough for me to scare you into having an operation.

Louise King

Thank you. Okay Linda says her veins are not painful but they're very unsightly and are also on the shin as per the diagram. She takes, sorry if I said this wrong, rivaroxaban, does this cause a problem?

Mr Chaloner

So rivaroxaban is – in common parlance - a blood thinner. We put patients on it for a variety of reasons; the commonest reason is a thing called atrial fibrillation which is when your heart doesn't beat in a regular fashion. And so most people are on it because of that. With regard to the veins, the threshold for surgery changes a bit, depending on how severe they are so as Aaron said, and I entirely agree with everything you said there, if it's grade three - so it's causing a bit of aching discomfort and all the rest of it - then surgery is optional. You can either choose to have surgery or you can just choose to leave them alone. Nothing awful will happen to you, your leg will not fall off or anything like that. You won't suddenly get a major problem. So, if the veins are not causing skin damage, then surgery is entirely your choice and we will provide it if you wish and we will tell you not to worry about it if you don't wish.

If you're on rivaroxaban, which is a blood thinner, it complicates things a little bit in the sense that you're more likely to bruise more substantially after surgery. So, depending on the reason why you're on rivaroxaban, usually we stop it for a couple of days beforehand, do the operation and then you restart it afterwards.

There are some circumstances where people are on rivaroxaban because they've had say recurrent DVTs and that might be a reason for leaving things alone. But on occasions we do operate on patients who are on rivaroxaban, and we carry on and keep them on rivaroxaban while we're doing it because the risk/reward ratio is in favour of doing it that way and it usually works out fine. But patients who are on blood thinners do get a bit more bruising than patients who aren't.

Louise King

Okay thank you, just two more questions. One lady says I've had varicose veins stripped on both legs, approximately 19 years ago. They've returned far worse on the right leg would I be suitable for laser treatment as you described? The stripping was awful!

Mr Sweeney

The answer is almost always we use a laser, but we would need to do an ultrasound first just to see the lie of the land just underneath the surface. Interestingly, stripping veins - which shouldn't really occur anymore - involves pulling the veins out it's quite a traumatic operation but also afterwards your body tries to heal itself and, in that process, it produces new veins, and those new veins don't have proper valves and sometimes they can produce even more veins than you had before you had your initial operation. So, it doesn't really matter if the surgeon was a fabulous surgeon who did a perfect operation, your own body produces new veins and that's why often after you've had your veins stripped you can get worse veins occurring a year or two years afterwards.

But to answer the question sometimes the operation wasn't done perfectly so what you thought you had was stripping your veins but in fact you didn't have that, you had just a height a tie of the vein up in the groin and quite often we find that there are lots of areas that need to have a laser placed in them just to clear up what perhaps wasn't done at the in the beginning.

But you do need an ultrasound done first. Nearly always 20 years ago and indeed when myself and Eddie were junior doctors, we didn't use the ultrasound machine. That was done by a radiologist. So, we were looking at the surface, more or less guessing what vein was not working and nowadays we have an ultrasound attached to us, rather like a stethoscope, and we spend most of our time looking underneath the surface just to see where everything is arising from.

So, quite often with recurrent veins, there's a bit left underneath and we would treat that with a laser. But the bumpy bits on the surface if they're loopy or quite extensive they often require a few small little incisions just to break them up and get rid of them and make them look cosmetically okay.

Louise King

Lovely, thank you, one last question, it's quite a quick one from Victoria, how long does the recovery take as in how soon can someone exercise after the treatment?

Mr Chaloner

Well, most people you’re more or less back to normal within a couple of weeks. Most of the bruising and the discomforts in the first week to 10 days. As a general principle we put the bandage on immediately after surgery and that stays on for about five days and, whilst the bandage is a bit of a nuisance, most patients find they don't have too much pain during that first five days because the bandage keeps everything compressed and under control. And the worst bit is usually when the bandage comes off because that's when you start to feel tight, usually down the inner side of the thigh and it feels a bit tight, feels a bit sore it feels a little bit like you pull the hamstring and it takes about the same amount of time to get better.

So, by the end of the first week most people are back to doing all their normal household activities, driving a car, doing the shopping, doing normal kind of things but they're still a little bit tender and they need to take some mild painkillers or use some anti-inflammatory gel. By day ten, things are starting to get better quite substantially and then after that every day usually it is much, much better. So, by the end of the second week, most people are back to light sports going back to do light gym work, going for a jog that kind of stuff. And usually by the end of the third week most people have forgotten about it they may still have a few bruises, but as far as the pain side of things is concerned it's all gone back to normal.

Now there are some patients who get better very much quicker than that and some patients who take a bit longer than that, but by and large 80% of the patients that we treat they have that sort of experience I've just described. 10% of people get better very, very quickly and wonder what all the fuss was about and 10% people come back to see us a couple of weeks later and say “Well it still hurts. You said it was going to be better by now!”. And I’ve said “Well, just give it another week or two and it will be.” And it usually is. So, two weeks really to get back to what most people regard as pretty much normal function.

Louise King

Okay, well thank you both very much for this informative chat this evening. I hope everyone listening and watching enjoyed it and thank you for going through the questions.

We’d really appreciate it if you're listening if you could do the survey at the end. This helps us shape future events and helps us give feedback to our wonderful consultants online. Our next event is on cataracts relating to special lenses it's with Damian Lake our Consultant Ophthalmology Surgeon and Jane Styche, our Eye Unit Sister, and that's on the 30th of March.

So otherwise, thank you very much for everyone joining and taking your time out of your evenings. Thank you, Eddie and Aaron, for your time and thank you for my colleagues for supporting this evening and I'll see you all soon. Thank you very much, bye.